Healthcare for the hard-up

A $40,000 hysterectomy: only $700.

Basic X-ray: only $10.

Dental cleaning: $45. Intensive care unit: $600 per day.

The Access to Healthcare Network's prices sound like a doctor's bill from the 1950s or '60s. So it's not surprising that the Reno-based nonprofit -- which provides affordable, comprehensive healthcare to the uninsured working poor in Washoe County, Nev. -- has seen its membership swell to more than 2,500 people since it opened in 2007. Director Sherri Rice expects another 2,500 to join by the end of this year.

"We are in such a healthcare crisis in our country," Rice says. "Hospitals and the uninsured want to look for a new way."

The Access Network operates on one basic principle: shared responsibility. Its roots go back to 2004, when a group of local stakeholders, including two big hospitals and the county and state health departments, began looking for a sustainable way to provide service to some of the community's poorest people. According to Rice, they weren't interested in "another entitlement program" such as Medicaid, which relies on federal and state funding and doesn't require patients to put much money or effort into their own care.

Now, the two hospitals and more than 450 other healthcare providers have agreed to offer their services at low fixed rates. In exchange, the Access Network guarantees that its members will pay cash at the time of service. It pairs each member with a "care counselor" who ensures that medical appointments and follow-up care will be handled responsibly.

It's a good deal for the providers -- which range from pharmacies to acupuncturists, optometrists to cardiologists -- because it allows them to serve needy people with the assurance they'll get some payment without a protracted collection effort. The hospitals are also able to cut down on their charity expenses. (Patients who can't afford specialty services or coherent care often end up in emergency rooms, and hospitals are frequently stuck with the bills.)

"We put structure to a structureless population," says Rice. "We have proved that people at poverty line can pay."

Nevada residents who earn between 100 percent and 250 percent of the federal poverty level are eligible. Aside from the fixed rates they pay to providers, they pay a monthly fee to the Access Network: $45 for an individual, $90 for a family. Some small-business owners help employees by paying a portion of the fees.

Rice has only expelled 10 members for failing to pay. No one, she says, has asked for free service. "They ask to pay what they can according to income. They ask for their dignity. We give them both."

--Terray Sylvester, freelancer

Developing to stop development

In 2001, Ted Harrison, working for the Trust for Public Land, acquired 1,400 acres of rabbitbrush and petroglyph-etched basalt boulders as open space for Santa Fe County, N.M. Nice accomplishment, but Harrison was frustrated: It was just a sliver of the more than 14,000-acre Thornton Ranch, which lies right in the path of Santa Fe's sprawl. And the Trust and the county couldn't afford to buy the entire ranch.

They did their best "to preserve discrete parcels," Harrison says, but "the real estate industry was washing away a lot of the effects."

So Harrison left the Trust and started the nonprofit Commonweal Conservancy. His group is now buying the remaining 13,222 acres of the Thornton Ranch south of Santa Fe, where it plans to create the Galisteo Basin Preserve: About 1,000 homes built on just 427 acres, with the rest set aside as open space.

Other developments in the West preserve more land, but typically they emphasize exclusivity and their open space becomes a "private refuge," Harrison says. Galisteo Basin Preserve is inclusive: No gates allowed, no golf courses and no country clubs -- and 10,000 acres of the open space will be open to the general public.

Ninety-five percent of the houses will be clustered in a 300-acre "village" that includes 30 percent county-approved affordable housing. There will be an environmentally oriented charter school and a commercial area to reduce the need for driving. Outside the village, some of the largest, most expensive lots are off-the-grid; their sales will help fund the rest of the land purchase. The village plan includes community gardens and a centralized rainwater-catchment and graywater-recycling center. Construction is slated to begin in 2010; a hundred-tree orchard has already been planted.

Harrison had to appease the residents of nearby Galisteo, who worried that the development would impact their water supply. He also reached out to include other nonprofits, from the Earthworks Institute, which is restoring arroyos, to the Quivira Coalition, which is fashioning a sustainable grazing strategy.

"Coming at this from a nonprofit perspective, part of the fun and craziness here is to see how many things we can fit together and really push the envelope," Harrison says. "If your goal is wealth maximization for a small group of investors, then these other social welfare ideas are not on the table."

Those ideas include a "memorial landscape" or environmentally friendly cemetery. "If we don't accommodate that," says Harrison, "well, of course, it's not a whole community."

--Jonathan Thompson, HCN senior editor

Innovator tidbit: St. George, Utah, is building a community-owned solar PV field on city land -- homeowners make a one-time payment (less than rooftop solar) and agree to buy the electricity for 19 years.

Saving journalism by 'crowdfunding'

Imagine you live in a place dominated by a single industry: oil-and-gas drilling, say, or real estate, or a university, or just single-minded, intolerant politics. You see unfairness or corruption and think that a hard-hitting investigation might lead to improvements. The local news operations tend to favor the status quo because they rely on advertising from the dominant industry or aren't equipped to investigate.

So you go to a Web site and propose the investigation you have in mind. You figure it could be done for $2,000, which would cover a journalist's time and expenses. You use your credit card to pledge $50 toward the total. You tell other people, and they tell others. Eventually, enough people make pledges to cover the full $2,000.

Then the Web site boss hires the right journalist, who does the story –– and blows the lid off whatever injustice you targeted.

Sound far-fetched? A year ago, it was. But today it's possible, thanks to a 26-year-old San Francisco innovator named David Cohn.

"I'm very passionate about journalism," Cohn says, especially "the concept of participatory journalism, or how the public can be engaged."

He invented www.Spot.us to engage the public. He launched it about five months ago, with $340,000 from the Miami-based Knight Foundation News Challenge program, which funds "media innovators" across the country.

Spot.us is one of many signs that journalism is changing. Daily newspapers, magazines and broadcast news shows are struggling financially as more people get their news online. But online news operations typically lack the staff or money for news-gathering.

Cohn grew up in California and got a master's degree at the Columbia University Journalism School in New York City. He worked as a researcher for Jeff Howe, a Wired editor who champions the idea of using "crowds" to fund different enterprises.

Cohn runs the site from the apartment he shares with his girlfriend and a cat, and from coffee shops with his notebook computer. The public has funded about a dozen Spot.us stories so far -- pitched by both journalists and ordinary citizens -- including investigations of the Oakland police and the problems of homeless people.

The focus is on the Bay Area, because the Knight award is for local journalism. But Cohn wants the idea to spread. He built Spot.us on an "open-source platform" -- anyone can modify the software to start doing journalism elsewhere. Asked how much time he's dedicating to it, he says, "It's basically if I'm not eating or sleeping. …"

--Ray Ring, HCN senior editor

Low-carb(on) brews

New Belgium Brewing makes at least 18 kinds of beer in Fort Collins, Colo., ranging from its famous Fat Tire Ale to whimsical seasonals such as Skinny Dip (only 114 calories per glass). By conventional standards, the company is the nation's third-largest craft brewer. It's also one of the most environmentally conscious companies on the planet, a path it pioneered beginning 18 years ago.

New Belgium buys all of its electricity from renewable sources, chiefly windmills, except for what it makes by burning methane from its own wastewater. The brewmaster boils his wort in an uber-efficient kettle imported from Germany, the first of its kind in this country. To trim the environmental costs of transporting and making cardboard, the company recently reduced the packaging material in each 12-pack; that alone cut yearly cardboard demand by 150 tons and shaved 174 metric tons from the estimated annual greenhouse gas emissions caused by the brewery's operations.

New Belgium has lowered its rate of water use with a new, technologically advanced bottling plant. To foster low-impact transportation, it gives bicycles to employees after they've been with the company for a year, and keeps a collection of loaner bikes on the property for lunch-break excursions. It also pays a bike courier to gather brown bottles from downtown bars and restaurants, because the city doesn't offer commercial recycling. It then ships those bottles, along with its own stream of waste glass, to the nearby Rocky Mountain Glass plant, where Coors bottles are born.

The company is working to brew more of its beer from organic ingredients, but has had trouble finding high-quality organic ingredients in the local market. So it's donated $20,000 to Colorado State University to spur research into Colorado's organic growing conditions.

Before bringing their first batch of beer to market in 1991, co-founders Jeff Lebesch and Kim Jordan hiked in the mountains to brainstorm a few basic sustainability principles for their company. They committed to "kindling social, environmental, and cultural change as a role model of a sustainable business." Ever since then, they and their staff have discarded the idea that profit-making conflicts with a commitment to the common good.

New Belgium believes that its green image underpins its brand strength. "We don't calculate the cost of doing something unsustainably and then more sustainably and figure out the difference," says New Belgium's sustainability director, Jenn Orgolini. "We're always looking for the next thing."

--Terray Sylvester, freelancer

Innovator tidbit: Headwaters Economics in Bozeman, Mont., invents software to uncover the hidden costs of community decisions, such as allowing new houses in wildfire zones or committing to a mining economy.